Promoting smoking cessation in lung cancer screening through proactive therapy: PROACT VA Medical Centers are beginning to offer eligible Veterans lung cancer screening following national recommendations including the US Preventive Services Task Force's ?B? recommendation for annual screening. Preliminary evidence from the VA Lung Cancer Screening Demonstration Project suggests that nearly 2.8 million Veterans will be eligible for screening and over half will be current smokers with a long history of smoking. It is critical that offering screening to current smokers reinforces the importance of cessation and does not reduce motivation to quit. Integrating cessation into lung cancer screening is challenging, in part because of limited time and clinic resources, but also because of misperceptions about the ?protective? effect of screening among many current smokers. In the National Lung Screening Trial, primary care providers offering screening adequately addressed smoking cessation with only 10% of current smokers. This project will provide proactive behavioral and pharmacotherapy treatment to all current smokers as part of participating in lung cancer screening. Tobacco treatment will be integrated with the reporting of screening results. In our pilot study of the proactive telephone counseling component of the proposed intervention, we increased participation in behavioral cessation treatment to 36% among intervention participants from 11% among usual care control patients, and quit rates more than doubled to 18% in the intervention group. Screening patients often report being motivated to participate in screening to find out how much smoking has harmed them. Our proposed intervention is designed to convert this new level of patient engagement into an opportunity to encourage cessation. Our proposed proactive care strategy removes the precondition of asking patients if they are ready to quit. Over 14 trials have shown providing opt-out treatment to all current smokers significantly increases quit rates. We will conduct a pragmatic randomized trial with current smokers at VA Puget Sound and VA NY Harbor who are participating in lung cancer screening. Patients will be randomized to receive either proactive care with opt- out treatment accompanying their screening results (n=250) or usual care (n=250). Proactive treatment will be arranged by a radiology-based coordinator, and will include a tailored results letter describing pharmacotherapy, an appropriate prescription ordered in conjunction with the patient's primary care provider, and two proactive telephone-based behavioral counseling sessions. The telephone counseling component will be delivered by counselors at VA's national quitline. The primary endpoint is biochemically confirmed 7-day abstinence 12 months after screening. Based on prior trials of opt-out treatment and our pilot data, the trial is powered to detect an improvement in quit rates from 9% with usual care to at least 18% with opt-out treatment.